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Assessing the barriers and facilitators of access to diabetic retinopathy screening in sub- Saharan Africa: a literature review


Diabetic retinopathy (DR) is the leading cause of blindness in working age adults. An increase in visual loss has been projected for sub-Saharan Africa (SSA) with the diabetes epidemic in the region. Screening is a cost-effective way to reduce this scourge, but adequate services are scarce. This review aims to evaluate the evidence on barriers and facilitators of access to DR screening with a view to making evidence-based recommendations for the development of effective and sustainable programmes in SSA. A systematic literature search of Africa-Wide Information, Embase, Cochrane library, Global Health, and Medline databases was done using diabetic retinopathy, screening, and Sub-Saharan Africa as concepts. Google Scholar was also searched to identify relevant literature. Studies were included if they were done in SSA and reported on barriers and/or facilitators of access to DR screening. The database search yielded 616 papers and google scholar yielded 9223 papers. Of these, 54 papers were assessed for eligibility and 18 met the inclusion criteria. These were appraised with appropriate checklists. Fourteen themes were synthesised. Most were supply challenges affecting all dimensions of access and the six components of the health systems building blocks. Several studies had poor methodologies, and this has implications for the evidence provided. The findings of this review show a weakness in the health systems suggesting this is the major indirect barrier to DR screening in SSA. Measures to strengthen the health system for DR screening is strongly recommended.


糖尿病视网膜病变(DR)是工作年龄成年人失明的主要原因。随着糖尿病在亚撒哈拉以南非洲地区 (SSA) 的流行, 预计失明将会增加。筛查是减少该病的一种具有成本效益的方法, 但是在服务方面仍旧欠缺。本综述旨在评估DR筛查中的障碍及促进因素的证据, 为SSA制定有效和可持续发展提出循证建议。

对Africa-Wide Information、Embase、Cochrane图书馆、全球健康和Medline数据库进行了系统的文献检索, 使用糖尿病视网膜病变、筛查和撒哈拉以南非洲作为主题词。使用谷歌学术搜索也来识别相关文献。研究如果在SSA开展并报告DR筛查的障碍和/或促进因素的研究则纳入本研究。数据库共搜寻到616篇论文, 谷歌学术9223篇论文。其中, 54篇论文具有符合评估标准, 18篇符合入选标准。评估表对这些研究进行总结与评估。

我们对十四个主题进行了分析。大多数是供应方面的挑战, 影响获取的各个方面卫生系统的六个组成部分方面的障碍。一些研究的方法论不佳, 这对所提供的证据有影响。

本综述结果显示了卫生系统的弱点, 是SSADR筛查中主要存在的间接障碍。本文强烈建议采取措施加强卫生体系中DR筛查系统。

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Fig. 1: A flow diagram showing the steps taken to identify the eligible studies included in the review.


  1. Cho NH, Shaw JE, Karurunga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW et al. IDF diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. Accessed 19 Sep 2019.

  2. IDF. Diabetes Atlas. 4th ed. Brussels: International Diabetes Federation, 2009.

  3. Cheung N, Mitchell P, Wong TY. Diabetic Retinopathy. Lancet. 2010;376:124–36.

    Article  PubMed  Google Scholar 

  4. Genz J, Scheer M, Trautner C, Zöllner I, Giani G, Icks A. Reduced incidence of blindness in relation to diabetes mellitus in southern Germany? Diabet Med. 2010;27:1138–43.

    Article  CAS  PubMed  Google Scholar 

  5. ICO Guidelines for Diabetic Eye Care. Accessed 16 Sep 2019.

  6. WHO: Blindness and vision impairment prevention. Priority eye diseases. Accessed 17 Sep 2019.

  7. IDF Diabetes Atlas. 6th ed. 2013. Accessed 17 Sep 2019.

  8. Burgess PI, Msukwa G, Beare NAV. Diabetic retinopathy in sub-Saharan Africa: meeting the challenges of an emerging epidemic. BMC Med. 2013;11:157.

  9. Rotimi C, Daniel H, Zhou J, Obisesan A, Chen G, Chen Y, et al. Prevalence and determinants of diabetic retinopathy and cataracts in West African type 2 diabetes patients. Ethn Dis. 2003;13:S110–7.

    PubMed  Google Scholar 

  10. Lu Y, Serpas L, Genter P, Anderson B, Campa D, Ipp E. Divergent perceptions of barriers to diabetic retinopathy screening among patients and care providers, Los Angeles, California, 2014-2015. Prev Chronic Dis. 2016;13:1–8.

    Article  Google Scholar 

  11. Onakpoya OH, Adeoye AO, Kolawole BA. Determinants of previous dilated eye examination among typeII diabetics in Southwestern Nigeria. Eur J Intern Med. 2010;21:176–9.

    Article  PubMed  Google Scholar 

  12. Aveyard, H. Doing a literature review in health and social care: a practical guide 4th ed. Berkshire, England. 2019.

  13. The PRIMA Flow Diagram. Accessed 8 Mar 2020.

  14. Saurman E. Improving access: modifying Penchansky and Thomas’s theory of access. J Health Serv Res Policy. 2016;2:36–9.

    Article  Google Scholar 

  15. WHO and alliance for health policy and systems research: SYSTEMS THINKING for health systems strengthening (English). .Accessed 10 May 2020.

  16. An overview of different health systems frameworks Accessed 19 Jul 2020.

  17. Critical Appraisal Skills Programme (2018). CASP (Qualitative) Checklist. [online] Available at: URL. Accessed: Date 16 Jul 2020.

  18. Axis critical appraisal of cross-sectional studies.… · PDF file. Accessed 16 Jul 2020.

  19. Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Mixed Methods Appraisal Tool (MMAT), version 2018. registration of Copyright (#1148552), Canadian Intellectual Property Office, Industry Canada. Accessed 16 Jul 2020.

  20. Kizor-Akaraiwe NN, Ezegwui IR, Oguego N, Uche NJ, Asimadu I, Shiweobi J. Prevalence, awareness and determinants of diabetic retinopathy in a screening centre in Nigeria. J Community Health. 2016;41:767–71.

    Article  PubMed  Google Scholar 

  21. Cleland CR, Burton MJ, Hall C, Hall A, Courtright P, Makupa WU, et al. Diabetic retinopathy in Tanzania: prevalence and risk factors at entry into a regional screening programme. Tropical Med Int Health. 2016;21:417–26.

    Article  Google Scholar 

  22. Arnolds NC. Factors influencing attendance by diabetic patients for their yearly ophthalmic reviews at a private ophthalmic practice in East London, South Africa . A Dissertation submitted in fulfillment of the requirements for the degree: master of nursing science (magister of curationis) (medical-surgical nursing). 2016.

  23. Lagatt CF, Harun K. Knowledge, attitude, and predictors of diabetic retinopathy screening among patients with type 2 diabetes in Nairobi County, Kenya. J Health Soc Sci. 2019;4:253–64.

    Google Scholar 

  24. Olokoba LB, Mahmud OA, Adepoju FG, Olokoba AB. Awareness of Diabetic Retinopathy among Patients with Diabetes Mellitus in Ilorin, Nigeria. Sudan J Med Sci. 2017;12 89–100.

  25. Assem AS, Tegegne MM, Alemu DS, Woredekal AT, Tefera TK. Knowledge about diabetic retinopathy, eye check-up practice and associated factors among adult patients with diabetes mellitus attending at debark hospital, Northwest Ethiopia. BMC Ophthalmol. 2020 Nov;20:453. PMID: 33208125; PMCID: PMC7672967.

  26. Momoh ZD, Agweye CT, Oguntolu V, Nkanga D. Diabetic retinopathy screening in Calabar, Nigeria:factors influencing referrals and uptake of screenings ervice. Niger J Ophthalmol. 2017;25:118–22.

    Google Scholar 

  27. Ibrahim OA, Foster A, Oluleye TS. Barriers to an effective diabetic retinopathy service in Ibadan Nigeria (sub –Saharan Africa) - a pilot qualitative study. Ann Ib Postgrad Med. 2015;13:36–43.

    CAS  PubMed  PubMed Central  Google Scholar 

  28. Wentzel A, Mchiza ZJ. Exploring Factors Associated with Diabetic Retinopathy Treatment Compliance Behaviour in Cape Town, South Africa. Int J Environ Res Public Health. 2021 Nov;18:12209. PMID: 34831965; PMCID: PMC8617604.

  29. Hall CE, Hall AB, Kok G, Mallya J, Courtright P. A needs assessment of people living with diabetes and diabetic retinopathy. BMC Res Notes. 2016;9:56

    Article  PubMed  PubMed Central  Google Scholar 

  30. Hall CE, Hall AB, Mallya J, Courtright P, Kok G. Developing comic strips promoting diabetic retinopathy screening in Kilimanjaro, Tanzania, using intervention mapping. Eye (Lond). 2022;36(May):25–32.

    Article  PubMed  Google Scholar 

  31. Abdulsalam S, Ibrahim A, Saidu H, Muazu M, Aliyu UT, Umar HI, et al. Knowledge, attitude, and practice of diabetic retinopathy among physicians in northwestern Nigeria. Niger J Clin Pract. 2018;21:478–83.

    CAS  PubMed  Google Scholar 

  32. Magan T, Pounceya A, Gadhvia K, Kattaa M, Posner M, Davey C. Prevalence and severity of diabetic retinopathy in patients attending the endocrinology diabetes clinic at Mulago Hospital in Uganda. Diabetes Res Clin Pract. 2019;52:65–70.

    Article  Google Scholar 

  33. Njambi L. Prevalence of diabetic retinopathy and barriers to uptake of diabetic retinopathy screening at Embu Provincial General Hospital, Central Kenya. East Afr J Ophthalmol. 2012;16:5–11.

    Google Scholar 

  34. Mwangi N, Bascaran C, Ng'ang'a M, Ramke J, Kipturgo M, Gichuhi S, et al. Feasibility of a cluster randomized controlled trial on the effectiveness of peer-led health education interventions to increase uptake of retinal examination for diabetic retinopathy in Kirinyaga, Kenya: a pilot trial. Pilot Feasibility Stud. 2020;6(Jul):102

    Article  PubMed  PubMed Central  Google Scholar 

  35. Oenga RB. Diabetic Retinopathy; knowledge, attitudes and practice among general practitioners in provincial hospitals in Kenya. A dissertation submitted in part fulfillment for the Degree of Master of Medicine in Ophthalmology University of Nairobi. 2012.

  36. Omar FJ, Sheeladevi S, Rani PK, Ning G, Kabona G. Evaluating the effectiveness of opportunistic eye screening model for people with Diabetes attending Diabetes clinic at Mnazi Mmoja hospital, Zanzibar Omar et al. BMC Ophthalmol. 2014; 14:81

  37. Oluwole D. Health Policy Development in Sub-Saharan Africa: National and International Perspectives. Accessed 25 Jul 2020.

  38. Global Economic Prospects: Sub-Saharan Africa. A Brief.

  39. Policy Research Working Paper 8425. Infrastructure Development in Sub-Saharan Africa A ScorecardCésar CalderónCatalina CantúPunam Chuhan-Pole)… Accessed 25 Jul 2020.

  40. Kellet J. A chance for universal healthcare in sub-Saharan Africa. .Accessed 25 Jul 2020.

  41. State of Health Financing in the African region . Accessed 25 Jul 2020.

  42. Mwangi N, Macleod D, Gichuhi S, Muthami L, Moorman C, Bascaran C, et al. Predictors of uptake of eye examination in people living with diabetes mellitus in three counties of Kenya. Tropical Med Health. 2017;45:41.

    Article  Google Scholar 

  43. Piyasena MMPN, Murthy GVS, Yip JLY, Gilbert C, Zuurmond M, Peto T, et al. Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings. PLoS One. 2019;14(Apr):e0198979

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Graham-Rowe E, Lorencatto F, Lawrenson JG, Burr JM, Grimshaw JM, Ivers N, et al. Barriers to and enablers of diabetic retinopathy screening attendance: a systematic review of published and grey literature. Diabet Med. 2018;35:1308–19.

    Article  CAS  PubMed  Google Scholar 

  45. Chan JC, Gagliardino JJ, Baik SH, Chantelot JM, Ferreira SR, Hancu N, et al. Multifaceted determinants for achieving glycemic control: the International Diabetes Management Practice Study (IDMPS). Diabetes Care. 2009;32:227–33.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Dennis RA, Pullen KR. Improving access to emergency healthcare in sub -Saharan Africa. Accessed 26 July 2020.

  47. Scanlon PH. The English national screening programme for diabetic retinopathy 2003-2016. Acta Diabetol. 2017;54:515–25.

    Article  PubMed  PubMed Central  Google Scholar 

  48. National Health and Medical Research Council. Clinical Practice guidelines: management of diabetic retinopathy. Canberra: Commonwealth of Australia, 1997. Available at Accessed 17 Sep 2019.

  49. Liese B. The State of the Health Workforce in Sub-Saharan Africa: Evidence of Crisis and Analysis of Contributing Factors. Africa Region Human Development Working Paper Series…/pdf/328040Health0workforce0AFHD0No175.pdf. Accessed 26 Jul 2020.

  50. Health promotion. Track 2: Health literacy and health behaviour .Accessed 26 Jul 2020.

  51. American Diabetes Association. Executive summary: standards of medical care in diabetes—2010. Diabetes Care. 2010;33:S4–10.

    Article  Google Scholar 

  52. Tonna AP, Weidmann AE, Laing RB, Tonna I, Macartney GM, Paudyal V, et al. A qualitative study of determinants of patient behaviour leading to an infection related hospital admission. J R Coll Physicians Edinb. 2017;47(Mar):40–46.

    Article  CAS  PubMed  Google Scholar 

  53. Everybody’s Business Strengthening Health Systems to improve health outcomes. WHO framework for action. .Accessed 19 Jul 2020.

  54. Oleribe OO, Momoh J, Uzochukwu BS, Mbofana F, Adebiyi A, Barbera T, et al. SD. identifying key challenges facing healthcare systems in Africa and potential solutions. Int J Gen Med. 2019;12:395–403.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Cleland CR, Burton MJ, Hall C, Hall A, Courtright P, Makupa WU, et al. Diabetic retinopathy screening: experiences from northern Tanzania. Lancet Diabetes Endocrinol. 2016;4:10–2.

    Article  PubMed  Google Scholar 

  56. Khandekar R, Shah S, Al, Lawatti J. Retinal examination of diabetic patients: knowledge, attitudes and practices of physicians in Oman. East Mediterr Health J. 2008;14:850–7.

    CAS  PubMed  Google Scholar 

  57. Wahidin M. Cervical cancer screening financing in Indonesia. J Glob Oncol. 2018;4:93s–93s.

    Article  Google Scholar 

  58. Poore S, Foster A, Zondervan M, Blanchet K. Planning and developing services for diabetic retinopathy in Sub-Saharan Africa. Int J Health Policy Manag. 2015;4:19–28.

    Article  PubMed  Google Scholar 

  59. Omari NS. The prevalence and determinants of diabetic retinopathy in Botswana: findings from a screening programme. A dissertation submitted in fulfilment of the requirements for the degree: Master of Public Health. Accessed 17 Sep 2020.

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Authors and Affiliations



EOA was responsible for designing the protocol for the review, conducting the search, screening for eligible studies, critical appraisal of studies, extracting data, data analysis, and interpretation, writing, summarising the findings, and approved the final version. OEO contributed to screening for eligible results, data analysis, writing the report, reviewed the manuscript, and approved the final version. NCO contributed to the initial searching as well as screening for eligible studies, data extraction, analysis, writing of the review, and approved the final version. AM was involved in the designing and writing of the review protocol, interpreting results, reviewed the manuscript, and approved the final version.

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Correspondence to Eberechukwu Ogbeanu Achigbu.

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Achigbu, E.O., Onyia, O.E., Oguego, N.C. et al. Assessing the barriers and facilitators of access to diabetic retinopathy screening in sub- Saharan Africa: a literature review. Eye (2023).

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